Healthcare Provider Details

I. General information

NPI: 1598559577
Provider Name (Legal Business Name): AMAR JITIN MAHBUBANI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 WEALTHY ST SE STE 2C-250
GRAND RAPIDS MI
49506-2921
US

IV. Provider business mailing address

1840 WEALTHY ST SE STE 2C-250
GRAND RAPIDS MI
49506-2921
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-0101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number5151017335
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: